Nokea
Which laboratory study is monitored for the patient receiving heparin therapy?
- A. INR
- B. PTT
- C. PT
- D. Bleeding time
Correct Answer: B
Rationale: The correct answer is B: PTT (Partial Thromboplastin Time) because it specifically measures the effectiveness of heparin therapy by assessing the intrinsic pathway of the coagulation cascade. A prolonged PTT indicates that heparin is achieving the desired anticoagulant effect.
A: INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin.
C: PT (Prothrombin Time) is also used to monitor warfarin therapy.
D: Bleeding time is not typically used to monitor heparin therapy and is more focused on platelet function rather than coagulation factors.
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The nurse understands that a patient with BP readings 164/102 and 176/100 on two separate occasions would be classified in which hypertension category?
- A. Prehypertension
- B. Stage 2
- C. Stage 1
- D. Posthypertension
Correct Answer: B
Rationale: The correct answer is B: Stage 2 hypertension. The patient's BP readings consistently fall within the range of 160-179 systolic or 100-109 diastolic, which aligns with the criteria for Stage 2 hypertension based on the current guidelines. This classification indicates a higher level of hypertension that requires prompt medical attention and intervention to reduce the risk of complications. Choices A, C, and D are incorrect because they do not correspond to the BP readings provided, falling outside the range for prehypertension, Stage 1 hypertension, and posthypertension.
A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
- A. “A man should wear a latex condom during intimate sexual contact.”
- B. “I’ve heard about people who got AIDS from blood transfusions.”
- C. “I won’t donate blood because I don’t want to get AIDS.”
- D. “IV drug users can get HIV from sharing needles.”
Correct Answer: C
Rationale: The correct answer is C. This statement warrants clarification as donating blood does not put individuals at risk of getting HIV. Blood donation involves a sterile process that ensures safety. Choice A is correct as using condoms can help prevent the transmission of HIV. Choice B is incorrect because modern blood screening techniques have greatly reduced the risk of HIV transmission through blood transfusions. Choice D is also correct as sharing needles is a high-risk behavior for HIV transmission. In summary, only choice C is incorrect as donating blood does not pose a risk of acquiring HIV.
According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?
- A. Ineffective airway clearance
- B. Ineffective coping
- C. Impaired urinary elimination
- D. Risk for body image disturbance
Correct Answer: D
Rationale: The correct answer is D: Risk for body image disturbance. In the context of Maslow's hierarchy of needs, physiological needs take precedence over psychological needs. For a client in the intensive care unit with congestive heart failure, ensuring physiological needs like airway clearance, urinary elimination, and coping are addressed first is crucial for survival. Body image disturbance is a higher-level psychological need and can be addressed once basic physiological needs are met. Therefore, addressing the risk for body image disturbance would have the lowest priority compared to the other options provided.
The nurse understands that labyrinthitis is treated primarily with which of the ff. drug categories?
- A. Antihistamines
- B. Anti-inflammatories
- C. Antispasmotics
- D. Antiemetics
Correct Answer: A
Rationale: The correct answer is A: Antihistamines. Labyrinthitis is an inner ear condition often caused by inflammation or infection. Antihistamines help reduce symptoms like vertigo and dizziness by decreasing inflammation and fluid buildup in the inner ear. Anti-inflammatories (choice B) may help with inflammation but are not as effective for inner ear conditions. Antispasmotics (choice C) are not typically used for treating labyrinthitis. Antiemetics (choice D) are used to control nausea and vomiting, which can be symptoms of labyrinthitis but do not address the underlying cause.
After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data?
- A. Auscultation of the lungs
- B. Complaint of nausea
- C. Sensation of burning in her epigastric area
- D. Belief that demons are in her stomach
Correct Answer: A
Rationale: The correct answer is A because auscultation of the lungs involves direct observation and measurement, making it objective data. This data is based on what the nurse hears through the stethoscope, which can be verified and measured. Choices B, C, and D involve subjective experiences or interpretations that cannot be directly observed or measured. Complaint of nausea, sensation of burning, and belief in demons are all based on the client's feelings, perceptions, or beliefs, which are subjective and can vary from person to person. Objective data is factual, measurable, and observable, making choice A the correct answer in this scenario.